Sample - PCAOB

1 form AP AUDITOR REPORTING OF CERTAIN AUDIT PARTICIPANTS Registered public accounting firms must report information about certain participants in the audit and any amendments thereto to the PCAOB by completing and submitting this form according to the instructions to form AP. It is important to refer to the instructions when completing each item of the form . The Firm is responsible for completing each item according to the instructions, and should not merely rely on the Firm s own interpretation of the item descriptions appearing in this form . Italicized terms are defined in PCAOB Rule 1001, except for the definition of "other accounting firm" which appears in the general instructions to form AP. The Firm must apply those definitions in completing the form . PART I - IDENTITY OF THE FIRM ITEM - NAME OF THE FIRM a.

2 Firm legal name b. If different than its legal name, state the name under which the Firm issued this audit report. PART II - AMENDMENTS ITEM - AMENDMENTS If this is an amendment to a report previously filed with the Board - a. Indicate, by checking the box corresponding to this item, that this is an amendment. gfedcb. Identify the specific Part or Item number(s) of this form (other than this Item ) as to which the Firm's response has changed from that provided in the most recent form AP or amended form AP filed by the Firm with respect to an audit report related to the issuer named in Item gfedcPart I, Identity of the Firm l Part III, Audit Client and Audit Report gfedcItem , Audit Report gfedcItem , Other Accounting Firms gfedcItem , Divided Responsibility l Part IV, Responsibility for the Audit is Not Divided gfedcItem , Other Accounting Firm(s) Individually 5% or Greater of Total Audit Hours gfedcItem , Other Accounting Firm(s)

3 Individually Less Than 5% of Total Audit Hours gfedcPart V, Responsibility for the Audit is Divided gfedcPart VI, Certification of the Firm If you check this box, use the text field below to describe the error or omission in Part VI as previously filed and to supply the information as it should have been provided in the previous submission. Use Part VI of this amended form only to certify the amended form , not to supply corrections to the previous form . Italicized terms are defined in PCAOB Rule 1001, except for the definition of "other accounting firm" which appears in the general instructions to form AP. The Firm must apply those definitions in completing the form . PART III - AUDIT CLIENT AND AUDIT REPORT ITEM - AUDIT REPORT a. Provide the following information concerning the issuer for which the Firm issued the audit report - 1.

4 Indicate, by checking the box corresponding to this item, if the audit client is an: nmlkjIssuer, other than employee benefit plan or investment company nmlkjEmployee Benefit Plan nmlkjInvestment Company 2a. Central Index Key (CIK) number, if any gfedcCheck here, if none 2b. Fund Series, if any Series Identifier Fund Name 3. The name of the issuer whose financial statements were audited 4. Date of the audit report (mm/dd/yyyy) 5. The end date of the most recent period's financial statements identified in the audit report (mm/dd/yyyy) 6. The name (that is, first and last name, all middle names and suffix, if any) of the engagement partner on the most recent period's audit, his/her Partner ID, and any other Partner IDs by which he/she has been identified on a form AP filed by a different registered public accounting firm or on a form AP filed by the Firm at the time when it had a different Firm ID Family name (last name) Given name (first name) Middle name Suffix Partner ID Previously reported Partner ID(s) 7.

5 The office of the Firm issuing the audit report Country City State b. Indicate, by checking the box corresponding to this item, if the most recent period and one or more other periods presented in the financial statements identified in Item were audited during a single audit engagement. gfedcc. In the event of an affirmative response to Item , indicate the periods audited during the single audit engagement for which the individual named in Item served as engagement partner (for example, as of December 31, 20XX and 20X1 and for the two years ended December 31, 20XX). d. Indicate, by checking the box corresponding to this item, if the audit report was dual-dated pursuant to AS 3110, Dating of the Independent Auditor's Report. gfedce. In the event of an affirmative response to Item , indicate the date of the dual-dated information.

6 Note: In responding to Item , the Firm should provide each date of any dual-dated audit report. Date(s) of the dual-dated audit report (mm/dd/yyyy) If different from the engagement partner named in Item , provide information about the engagement partner who audited the information within the financial statements to which the dual-dated opinion applies. Family name (last name) Given name (first name) Middle name Suffix Partner ID Previously reported Partner ID(s) ITEM - OTHER ACCOUNTING FIRMS Indicate, by checking the box corresponding to this item, if one or more other accounting firms participated in the Firm's audit. If this item is checked, complete Part IV. By checking this box, the Firm is stating that it is responsible for the audits or audit procedures performed by the other accounting firm(s) identified in Part IV and has supervised or performed procedures to assume responsibility for their work in accordance with PCAOB standards.

7 Note: For purposes of Item , an other accounting firm participated in the Firm's audit if (1) the Firm assumes responsibility for the work and report of the other accounting firm as described in paragraphs . of AS 1205, Part of the Audit Performed by Other Independent Auditors, or (2) the other accounting firm or any of its principals or professional employees was subject to supervision under AS 1201, Supervision of the Audit Engagement. gfedcITEM - DIVIDED RESPONSIBILITY Indicate, by checking the box corresponding to this item, if the Firm divided responsibility for the audit in accordance with AS 1205, Part of the Audit Performed by Other Independent Auditors, with one or more other public accounting firm(s). If this item is checked, complete Part V. gfedc Italicized terms are defined in PCAOB Rule 1001, except for the definition of "other accounting firm" which appears in the general instructions to form AP.

8 The Firm must apply those definitions in completing the form . PART IV - RESPONSIBILITY FOR THE AUDIT IS NOT DIVIDED In responding to Part IV, total audit hours in the most recent period's audit should be comprised of hours attributable to: (1) the financial statement audit; (2) reviews pursuant to AS 4105, Reviews of Interim Financial Information; and (3) the audit of internal control over financial reporting pursuant to AS 2201, An Audit of Internal Control Over Financial Reporting That Is Integrated with An Audit of Financial Statements. Excluded from disclosure and from total audit hours in the most recent period's audit are, respectively, the identity and hours incurred by: (1) the engagement quality reviewer; (2) the person who performed the review pursuant to SEC Practice Section Appendix K; (3) specialists engaged, not employed, by the Firm; (4) an accounting firm performing the audit of the entities in which the issuer has an investment that is accounted for using the equity method; (5) internal auditors, other company personnel, or third parties working under the direction of management or the audit committee who provided direct assistance in the audit of internal control over financial reporting; and (6) internal auditors who provided direct assistance in the audit of the financial statements.

9 Hours incurred in the audit by entities other than other accounting firms are included in the calculation of total audit hours and should be allocated among the Firm and the other accounting firms participating in the audit on the basis of which accounting firm commissioned and directed the applicable work. In responding to Part IV, if the financial statements for the most recent period and one or more other periods covered by the audit report identified in Item were audited during a single audit engagement (for example, in a reaudit of a prior period(s)), the calculation should be based on the percentage of audit hours attributed to such firms in relation to the total audit hours for the periods identified in Item Actual audit hours should be used if available. If actual audit hours are unavailable, the Firm may use a reasonable method to estimate the components of this calculation.

10 The Firm should document in its files the method used to estimate hours when actual audit hours are unavailable and the computation of total audit hours on a basis consistent with AS 1215, Audit Documentation. Under AS 1215, the documentation should be in sufficient detail to enable an experienced auditor, having no previous connection with the engagement, to understand the computation of total audit hours and the method used to estimate hours when actual hours were unavailable. Indicate, by checking the box, if the percentage of total audit hours will be presented within ranges in Part IV. gfedcITEM - OTHER ACCOUNTING FIRM(S) INDIVIDUALLY 5% OR GREATER OF TOTAL AUDIT HOURS Firm IDCheck here if no Firm ID is availablegfedcPercentage of participation% or rangeLegal name Headquarters office location: Country CityStateNote 1: In responding to Items and , the percentage of hours attributable to other accounting firms should be calculated individually for each firm.